Running head: HEALTH IMPACT/FRAMEWORK RESEARCH PAPER 1

Health Impact/Framework Research Paper

Cardiovascular disease in India

Delaware Technical Community College

NUR 310 Global Health

Melissa Utterback

May 1, 2017
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Abstract

Cardiovascular disease is the leading cause of death globally. Low and middle income countries

carry a high burden of disease accounting for at least three quarters of the global number of

deaths related to cardiovascular disease. India carries one of the highest burdens of disease for

cardiovascular disease, with the prevalence expected to continue to rise sharply in the future.

Risk factors for cardiovascular disease include tobacco abuse, diets high in fat and cholesterol,

physical inactivity, hypertension and high cholesterol levels in the blood. India has seen a large

shift of population from rural to urban areas. Urbanization has resulted in a drastic change of

lifestyle for many with more sedentary jobs, increased intake of fast food and processed food,

stress and increased abuse of tobacco products. Cardiovascular disease affects Indians about ten

years in age sooner when compared to higher income countries, affecting the financial stability

of the person, family and country. Country wide programs to promote healthy diets and activity

as well as anti-tobacco campaigns would be beneficial to all people in India. Ensuring all people

have access to cardiovascular disease prevention is imperative to decreasing the burden of

disease. Designing a therapeutic treatment regimen that is easy to adhere to such as the use of a

poly pill, as well as supported with evidence based practice, would ensure compliance with those

with cardiovascular disease and hopefully decrease the burden, as well as the mortality, of

cardiovascular disease. There are many successful treatment regimens currently in use in high

income countries that India could build and adapt from. Establishing a thorough plan that

incorporates disease prevention and maintenance, it will be possible to decrease the burden of

cardiovascular disease in India in time.

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Health Impact/Framework Research Paper

Cardiovascular disease in India

Cardiovascular disease is the number one killer globally killing about 17.5 million people

each year. (World Health Organization, n.d.). Cardiovascular disease, or CVD, includes

atherosclerotic disease, heart disease, stroke, heart failure, arrhythmia and heart valve problems

(American Heart Association, 2017). Heart attack and embolic stoke occur from a blood clot

preventing flow to the heart and brain respectively (American Heart Association, 2017). The

resulting lack of blood flow results in cell death, either in the heart with a heart attack, or in the

brain with a stroke. These blood clots are often caused by atherosclerosis, or plaque buildup

along blood vessels throughout the body. A hemorrhagic stoke, which is caused by hypertension,

occurs from a blood vessel bursting in the brain. Areas of the brain supplied by the broken vessel

are no supplied with blood and quickly results in cell death. Heart failure occurs when the heart

is no longer pumping effectively. Heart arrhythmia is an abnormal heart rhythm. Heart valve

problems occur when the valves of the heart no longer open and close effectively as they should

(American Heart Association, 2017.). About eighty percent of cardiovascular deaths result from

heart attack and stroke (World Health Organization, n.d.).

Once thought to only be a significant disease in higher income countries, cardiovascular

disease has now burdened countries of all income levels. In fact, low and middle income

countries account for over seventy five percent of CVD deaths globally (Praveen, et al., 2013).

The burden of cardiovascular disease is staggeringly high in India and is the leading cause of

death, accounting for about one quarter of all deaths in India (Prabhakaran, Jeemon & Roy,

2016). As overwhelming as the disease is today, the effects of cardiovascular disease are
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expected to rise in India. The effects of cardiovascular disease strike all people of India, from

urbanized areas to even the most rural. When compared to persons of European descent, Indians

are effected by cardiovascular disease by almost a decade earlier (Prabhakaran, Jeemon & Roy,

2016). Persons in India are being affected during their most productive adult years. The fact that

Indians experience CVD at an earlier point in their life has significant effects on their ability to

work, their family life, their ability to contribute to society and the economy. As deadly and

debilitating as CVD is, the truth is that CVD is largely preventable and its onset can easily be

delayed. Risk factors for cardiovascular disease include tobacco abuse, hypertension, physical

inactivity, high cholesterol, stress and diets high in fat and salt and low in wholes grains, fruits

and vegetables.

One of the largest modifiable risk factors in India is the use of tobacco products. It is

estimated that about one third of Indians abuse tobacco, with rates varying significantly by

region (Prabhakaran, Jeemon & Roy, 2016). Bidi, a hand-rolled leaf wrapped tobacco product,

and smokeless tobacco are most popular in India (Prabhakaran, Jeemon & Roy, 2016). Smoking

of tobacco products tends to be more prevalent among men and those with less education, and is

increasingly becoming popular among individuals aged 20-35 years (Prabhakaran, Jeemon &

Roy, 2016). Smoking tobacco has been shown to increase the likelihood of blood clotting,

elevate blood pressure and decrease a persons tolerance for activity all of which contribute to

CVD (American Heart Association, 2014).

Diet is another risk factor that could easily be changed to prevent CVD. As India

continues to transition from rural to urban living, diets are quickly changing too. Indians on

average consume too little fruits and vegetables in their diets (Prabhakaran, Jeemon & Roy,

2016). Many people in India report eating less than one serving of fruit per week (Prabhakaran,
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Jeemon & Roy,2016). The cost of fruits and vegetables in India tends to be relatively high,

which could contribute to its poor consumption. Many Indians, about forty percent, follow faith-

based traditional trends and are vegetarian (Singh et al., 2014). While this portion of the

population refrains from eating fatty meats, they do typically consume diets high in fried and

processed foods and unrefined carbohydrates (Singh, et al., 2014). Rice has remained a

traditional staple in Indian foods, however white rice is commonly consumed instead of its

healthier alternative, whole grain brown rice. Interestingly, a common belief in several areas of

India is that brown rise is the food of the poor in which many prefer white rice to show they are

of a higher status (Singh et al., 2014). As many people move to urban slums, traditional diets

once filled with whole grains such as barely and millet are now replaced with the less nutritious

refined grains. Fast food and prepackaged processed foods are readily available in urban areas

and are often much less expensive than healthier alternatives. These foods are typically made

with trans fatty acids which raise cholesterol levels, particularly LDL which is better known as

the bad cholesterol. Consumption of trans fat has been shown to increase cholesterol and

increasing ones risk of developing CVD (U.S. Food & Drug Administration, 2017). Oils high in

saturated fats, such as sunflower and palm, are popular in Indian cooking. Diets containing

excessive amounts of saturated fats lead to high cholesterol, which increases the risk of CVD

(American Heart Association, 2017). According to the American Heart Association, an ideal diet

to prevent CVD involves eating a diet that includes plenty of fruits and vegetables, whole grains,

lean meat and fish, low fat dairy. Diets should limit salt, cholesterol and saturated fats.

The prevalence of hypertension among Indians is estimated to be about 30 percent and is

expected to continue to rise (Prabhakaran, Jeemon & Roy, 2016). While in most western

populations blood pressure has been on the decline, blood pressures are continuing to rise in
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India (Prabhakaran, Jeemon & Roy, 2016). In 2000, an estimated 118 million people in India

carried a diagnosis of hypertension. That number is projected to almost double by 2025 leaving

an estimated 213 million diagnosed with hypertension (Praveen et al., 2013). Hypertension is

also increased with poor dietary choices, tobacco abuse and physical inactivity.

The health impact pyramid, as explained by Thomas Frieden, is a five-tiered pyramid for

public health action. The bottom, larger tiers reach a larger percentage of the population and tend

to be more effective. At the bottom of the pyramid is the socioeconomic factors tier. This tier is

the largest and allows the opportunity to make the most difference (Frieden, 2010). With this

tier, India should focus on the reduction of poverty and improvements in education, especially

primary education. India should educate children about CVD prevention as early as possible,

make it common knowledge in the hopes that future generations will know how to effectively

prevent and decrease the burden of CVD. Once a diagnosis of cardiovascular disease is made,

medication management quickly follows. Cardiovascular disease is associated with long term

medication treatment regimens which can be very costly (Pandey & Meltzer, 2016). In low and

middle income countries such as India, medications constitute a substantial portion of treatment

spending (Pandey & Meltzer, 2016). When a population is poor, underreporting, underdiagnosing

and poor compliance due to lack to financial sources ten to be more prevalent (Prabhakaran,

Jeemon & Roy, 2016). Access to healthcare is poor in India, and what healthcare is available

carries high out of pocket costs (Praveen, et al., 2013). Access to and affordability of healthcare

and medications needs to be a priority for India.

According to Frieden The second tier of the pyramid represents interventions that

change the environmental context to make healthy options the default choice, regardless of

education, income, service provision, or other societal factors. Such interventions that India
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should invest in include bans on trans-fat and smoking in public places as well as taxing sugar

and tobacco products to decrease their heavy consumption. Also, India should encourage the

elimination of public sale advertisements of tobacco products and unhealthy food products,

especially in environments frequented by children. A current tax on cigarettes does currently

exist in India, however much of the population smokes tobacco in the form of bidi, which is not

included in the tax (Prabhakaran, Jeemon & Roy, 2016). Ensuring that tobacco in all forms are

taxed would encourage individuals to make healthier decisions. As people continue to move to

urban areas, these areas should encourage physical activity in ways such as increasing the

number of public parks, encouraging walking and providing schools and employers with gyms.

The next tier of the pyramid, long lasting protective interventions, is described by Frieden

as infrequent protective interventions that do not require ongoing clinical care. As opposed to

the previous two tiers, this tier focuses more on the individual itself. With CVD in India, early

screenings for high blood pressure and cholesterol need to be implemented. These screenings

would identify those most at risk for CVD.

The fourth tier of the pyramid, clinical interventions, is where most of the actual

treatment of CVD will take place. Medical care for CVD needs to be based on evidence based

practice and standardized throughout India. CVD treatment usually consists of several

medications which can be difficult for many to be compliant with. Ensuring that there are enough

medical facilities and professionals in the various communities is essential.

The last tier of the pyramid, counseling and educational interventions, is commonly the

least effective (Frieden, 2010). CVD prevention at this level would include dietary and exercise

counseling from medical professionals and population wide education on CVD prevention and
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risk factors. Ensuring that this information is available and accessible by the entire population is

essential. This education would be completed in the work and school settings. Ensuring this

education is consistently provided could prove effective.

Making CVD prevention a priority is an essential task India must accomplish to ensure

the health of its citizens. India can look at high income countries and their strategies for

combating CVD and adapt similar plans for India. An example of an excellent program that

provides a great framework for combatting Indias CVD crisis is the CDCs A Public Health

Action Plan to Prevent Heart Disease and Stroke. The Centers for Disease Control and

Prevention, or CDC, helps national and state agencies create and implement public health

strategies to combat CVD. The CDC frequently evaluate its policies, programs and interventions

for effectiveness, a task that would be necessary in a rapidly changing environment such as India.

This program also instructs how to survey populations for risk factors, trends and how to identify

those most at risk populations. The goals of this program include preventing risk factors;

increasing detection and treatment of risk factors; increasing early identification and treatment of

CVD; decreasing reoccurrences of cardiovascular events and developing skilled public health

workers to combat CVD (Centers for Disease Control and Prevention, 2015).

Current problems with health care in India include low use of evidence based practice,

low detection rates, low rates of awareness, low rates of treatment compliance and a lack of

surveillance among its population as whole (Prabhakaran, Jeemon & Roy, 2016). Innovative

methods to be developed and implemented to overcome these challenges.

Many opportunities exist in India for a career in global health. Medical professionals are

needed at all levels to combat the growing burden of cardiovascular disease. Research and
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development of programs, implementation of the programs and surveillance of the population

both nationally and locally are jobs that can exist within the field of global health.

Much of Indias attention for prevention goes to communicable disease, leaving studies,

research and progress on noncommunicable diseases such as CVD stagnant. Attention much shift

to noncommunicable diseases, including CVD, to reduce the cumbersome burden of

cardiovascular disease. India investing in its healthcare, communities and population wide

communities offers the possibility of less morbidity and mortality from cardiovascular diseases.
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References

American Heart Association. (2014, February 7.) Smoking & cardiovascular disease.

http://www.heart.org/HEARTORG/HealthyLiving/QuitSmoking/QuittingResources/Smo

king-Cardiovascular-Disease_UCM_305187_Article.jsp#.WQk7lYWcE5s

American Heart Association. (2017, March 14). What is cardiovascular disease? Retrieved from

http://www.heart.org/HEARTORG/Support/What-is -Cardiovascular-

Disease_UCM_301852_Article.jsp#.WQYD8YWcE5s

American Heart Association. (2017, March 24). Saturated fats. Retrieved from

https://healthyforgood.heart.org/Eat-smart/Articles/Saturated-Fats

Centers for Disease Control and Prevention. (2015, February 10). Division for heart disease and

stroke prevention. Retrieved from https://www.cdc.gov/dhdsp/about_us.htm

Frieden, T. (2010). A framework for public health action: the health impact pyramid. American

Journal Of Public Health, 100(4), 590-595. doi:10.2105/AJPH.2009.185652

Geddam, J. B., Kokku, S. B., Nagalla, B., Anupama, D., Vijaya, R. K. & Parttipati, A. K. (2015).

Diet, nutrition and cardiac risk factor profile of tribal migrant population in an urban

slum in India. Indian Journal of Community Health, 27(1), 77-85.

Pandey, K. R., & Meltzer, D. O. (2016). Financial burden and impoverishment due to

cardiovascular medications in low and middle income countries: an illustration from

India. Plos ONE, 11(5), 1-19. doi:10.1371/journal.pone.0155293

HEALTH IMPACT/FRAMEWORK RESEARCH PAPER
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Prabhakaran, D., Jeemon, P. & Roy, A. (2016, April 18). Cardiovascular diseases in India:

current epidemiology and future health. Circulation, 133(16), 1605-1620.

https://doi.org/10.1161/CIRCULATIONAHA.114.008729

Praveen, D., Patel, A., McMahon, S., Prabhakaran, D., Clifford, G. D., Maulik, P. K., &

Peiris, D. (2013). A multifaced strategy using mobile technology to assist rural primary

healthcare doctors and frontline health works in cardiovascular disease risk management:

protocol for the SMARThealth India cluster randomized controlled trial.

Implementation Science: IS, 8137. Doi:10.1186/1748-5908-8-137

Singh, P. N., Arthur, K. N., Orlich, M. J., James, W., Purty, A., Job, J.S. & Sabate, J., (2014).

Global epidemiology of obesity, vegetarian dietary patterns, and noncommunicable

disease in Asian Indians. American Journal of Clinical Nurtrition, 100 359S-64S.

doi:10.3945/ajcn.113.071571

U.S. Food & Drug Administration. (2017, March 17). Trans fat. Retrieved from

https://www.fda.gov/Food/ucm292278.htm

World Health Organization. (n.d.). Cardiovascular disease. Retrieved from

http://www.who.int/cardiovascular_diseases/en/